Advanced Heart Care at Home

A home-based program for high-risk heart failure patients

Opportunity

Heart failure (HF) is a chronic, progressive condition affecting millions of people. It is the leading cause of death for both men and women in the U.S. The costs associated with HF are approximately $30 billion annually, a large portion of which is accumulated during the end of life (EOL). Inadequate and untimely symptom management results in high rates of EOL hospitalization for HF patients.

Home-based palliative care can reduce hospital admissions and mortality for HF patients and increase earlier referrals to hospice at the EOL. At the start of this project, few HF patients at Penn Medicine received hospice care. And, those who did, did not do so soon enough to experience the full benefits of hospice and bereavement support, respectively.

Intervention

Advanced Heart Care at Home (AHCAH) is an HF-specific program that aims to serve high-risk patients in the home setting to improve symptoms and facilitate timely referrals to hospice care.

The program, offered by Penn Home Palliative Care and Penn Home Hospice, leverages an algorithm developed by Penn Medicine's Data Science team to identify patients at high-risk for mortality. AHCAH liaisons consult with eligible patients on an opt-out basis and facilitate referrals to AHCAH with case management at discharge, thereby improving care transitions.

Once enrolled, AHCAH patients receive disease-specific palliative care at home. Services include early nurse practitioner visits to address symptoms and advance care planning, IV diuretics, telemonitoring, nursing assessments, and social work visits. Care is closely coordinated with each patient's cardiologist or primary care physician. When appropriate, AHCAH facilitates a smooth transition to hospice care.

Impact 

AHCAH increases quality days at home for seriously ill HF patients.
 
During the initial pilot, the monthly census of HF patients receiving home-based palliative care increased ninefold, with patients spending an average of 38 days on palliative care. Among the patients enrolled in the AHCAH pilot, there was also an increase in timely referrals to hospice. The program was well-received by patients, with 86 percent reporting that they would recommend the service to a family member or loved one. We also observed a culture shift as care team members began to view palliative care as a bold and compassionate care option, rather than "death care."
 
AHCAH is the standard of care for all eligible HF patients at Penn Medicine. At scale, AHCAH patients receive home-based palliative care more often and sooner and have fewer emergency department visits and hospital admissions.
 
The team is currently running a randomized control trial to evaluate the impact AHCAH has on hospitalization days, hospice enrollment, hospice length of stay, utilization of IV diuretics, documentation of care goals, and acute care costs.
Phase 3: How we work
Collaborators

Nina O’Connor, MD
Esther Pak, MD 
Penn Medicine Data Science team

Innovation leads

Davis Hermann, MiD
Emersyn Dieckmeyer, M:IPD
Shivan Mehta, MD, MBA, MSHP

Platforms
Funding

Innovation Accelerator Program
Independence Blue Cross

Innovation Methods

Show me

Instead of relying on a verbal recount of experience, ask users to show you how they use a product or service. What people say they do is often quite different than what they do.

Observing users in action will help you understand the spectrum of experiences users can have with the same product or service.

Surveys, interviews, questionnaires, and focus groups don’t tell you what you need to know. Prompting users to show instead of tell often reveals what others have missed.

Show me
We learned that physicians, nurses, social workers, and other hospital staff had significant misconceptions and stigma about palliative care through interviews and observations. They viewed it as "death care" and worried that referring patients signaled that they were giving up on treatment.
 
In the initial stages of this work, we designed materials and even talking points to reframe palliative care as a service that improves a patient's quality of life and does not preclude treatment. 
Show me

Instead of relying on a verbal recount of experience, ask users to show you how they use a product or service. What people say they do is often quite different than what they do.

Observing users in action will help you understand the spectrum of experiences users can have with the same product or service.

Surveys, interviews, questionnaires, and focus groups don’t tell you what you need to know. Prompting users to show instead of tell often reveals what others have missed.

Show me

Through interviews and observations, we learned that cardiologists were concerned that home-based palliative care couldn't meet the specific clinical needs of HF patients.

They stressed the importance of diligently monitoring the patient's weight and quickly mobilizing IV diuretics when patients needed to expel excess fluid. These insights helped us identify IV diuretics and telemonitoring as services that would need to be included in the AHCAH model.

Journey map

A journey map is a visualization of a user's process to accomplish a task. Journey mapping involves plotting user actions onto a timeline.

Details on users' thoughts, emotions, and feedback are then added to the timeline to provide a holistic view of the experience or journey. Journey mapping will help you uncover what's working well in the current state and identify key pain points that need addressing.

You can build a journey map based on several users' observations, creating an archetype user journey, or you can use a template in real time as you conduct individual observations of users.

Download template

Journey map
We conducted chart reviews and data analysis to learn more about the experience of HF patients at the EOL.
 
We used this information to map patient journeys. In doing so, we uncovered that the need for IV diuretics drove many hospitalizations in this patient population. In initial pilots, we validated that if we incorporated IV diuretics into AHCAH's home-based services bundle, we could keep patients out of the hospital.
Nudge

Human decisions and behaviors are heavily influenced by the environment in which they occur.

A nudge is an intervention that gently steers individuals towards a desired action. Nudges change the way choices are presented, or information is framed without restricting choice - although some nudges do change available offerings to drive behavior change.

To learn more about types of nudges like defaults, active choice, financial and social incentives, and more, visit the Nudge Unit website.

Nudge
Through contextual inquiry, we learned that at the EOL, HF patients experience frequent exacerbations in their symptoms, subsequent hospital admissions, and then periods of recovery.
 
As a result of this frenetic cycle, cardiologists found it challenging to know when to socialize the idea of home palliative care with patients and often ended up starting conversations too late.
 
Once we had an algorithm to identify patients who were appropriate for referral to AHCAH, we experimented extensively with nudges that could prompt providers to take action earlier.
 
Initially, we sent messages to cardiologists, encouraging them to discuss AHCAH with their patients. However, we learned that cardiologists rarely acted on this information, despite tweaks to the message content, format, and timing.
 
We then made a subtle but significant change. Instead of asking the cardiologist to facilitate the discussion, we instead sent a message informing them that a liaison would speak to the patient about AHCAH unless they opted out.
 
Cardiologists very rarely opted out. AHCAH liaisons had productive conversations with patients and ensured that amenable patients were enrolled in the program.

Videos

Pitch Day 2018